Critique the practices of medical necessity and utilization management in the reimbursement process.

Instructions:

Concept to Consider:

Imagine you are the health information management director at your local hospital. It has just been announced that the hospital is going to evaluate the government-sponsored healthcare programs.

You have been asked to prepare a presentation to the hospital administration to help educate the healthcare providers about the reimbursement rates. In preparation for the development of your presentation, review the information in your text, supplemental reading including the

“toolkit,” and available websites for the most up-to-date information.

Part 1:

Prepare a Medicare Part A–D and Voluntary Choice grid. Your grid should be detailed and include the following: cost, deductibles, copayments, examples of covered services, and any other details you think are important.

It is also important that you make sure the grid is easy to understand. In addition, provide at least three websites or other services that the administration may want to use to help them to better understand the facts.

Name of insurance (topic)

Coverage

Premium

Deductible

Copayment

Enrollment provisions

Special circumstance

Narrative explanation to accompany the grid:

Provide a narrative to accompany your table explaining the medical coverage for the topics (Medicare Part A, Medicare Part B, Medicare Advantage, Medicare Part D, and Voluntary Insurance Plan). Create 1–2 paragraphs for each topic addressing the listed issues.

An example table is illustrated below. Your table may be developed in Excel or Word.

Sample Grid

Part 2:

Answer the following questions by performing a search:

National coverage determinations (NCDs) and local coverage determinations (LCDs) define the specific diagnosis and procedure codes that support medical necessity for many services provided.

Conduct a browser search for obtaining medical coverage determination information.

Enter “national coverage determinations” in the browser.

Note: Examine the NCD related to bariatric surgery for treatment of morbid obesity.

Questions

Create 1–2 paragraphs for each question:

1. Identify five procedures described in the bariatric surgery NCD.
2. Name three criteria a patient must meet to be eligible for Medicare payment for the surgery.
3. Identify the bariatric procedures not covered by Medicare.
4. Explain the relationship between DRGs and approved procedure — medical documentation.

Your presentation should:

1. Create a bibliography citing a minimum of three references according to APA format.
2. Resources can include your text and chapter references, organizational websites, or such resources as the American Medical Association, American Hospital Association, or the American Health Information Management Association.
3. The paper should include the following:
   • Part 1: The grid, five narrative explanations (1–2 paragraphs for each service)
   • Part 2: NCD search (including title or reference pages)
4. The paper should follow the conventions of Standard American English (correct grammar, punctuation, etc.).
5. Your writing should be well ordered, logical, and unified, as well as original and insightful. Your work should display superior content, organization, style, and mechanics.
6. You should cite sources using APA format.
7. Presentation must be professionally attractive.